Opportunities for Dental Disease Management

Programs in Managed Care

Jay Feldstein, DO, FACPM Keystone Mercy Health Plan

Lawrence Paul, DDS QualDent

David Williams, PhD QualDent

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Goal of Dental Disease Management

Reconnecting the Head and the Body

Oral Health in America: A Report of the Surgeon General (May 2000) provided state-of-the-science evidence on the growth and development of: oral, dental and craniofacial tissues and organs the diseases and conditions affecting them and the integral relationship between oral health and general health,

including recent reports of associations between: chronic oral infections and diabetes osteoporosis heart and lung conditions and certain adverse pregnancy outcomes 

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Keystone Mercy Health Plan

• 300,000 Medicaid members

• 6,000 in intensive case management

• 30,000 HBP, CAD

• 3,500 HF

• 10,000 deliveries per year

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DISEASE MANAGEMENT AND INTENSIVE CASE MANAGEMENT Blended model

High risk

Low risk

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CHRONIC DISEASE

Diabetes Mellitus Coronary Artery Disease HF

40% have at least 1 dental visit per year Part of disease management, case management

assessment

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PREGNANCY MANAGEMENT

Smiling Stork Program

Any reason Cleaning

Pregnant women seeing a dentist before intervention

24% 24%

Pregnant women seeing a dentist after intervention

58% 63%

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INCREASING DENTAL CARE

Member education

PCP education

Specialist education

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BARRIER ANALYSIS

Access

Cultural competency

Disparities

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DENTAL CARE

Care access point High blood pressure Diabetes Coronary artery disease Average dental costs = $43.84

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CLINICAL DENTAL MANAGEMENT

What happens in the Dental Office? The old paradigm of how dental health affects

systemic health ... The new paradigm of how dental health

affects systemic health … Why should the dentist do more than what

they currently provide?

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DENTIST TO TREAT A NEW POPULATION FOR THEM

Percent of population

Percent of annual cost

Healthy 70% 15%

Chronic 15% 40%

Acute 14% 20%

Complex 1% 25%

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DENTAL DM FOCUS ON 3 CONDITIONS

Diabetes often diagnosed through periodontal exams periodontal disease often decreases a diabetic’s ability to

control glucose levels

Coronary Artery Disease weakened gum tissue allows increases in oral bacteria into

the bloodstream, causing blood clots or clumps of blood cells

Pregnancy problems leading to preterm birth and associated low birth weight As many as 18% of all premature births may be associated

with periodontitis Periodontitis produces prostaglandins which send out a false

signal that prematurely initiates the birth process

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DENTAL INTERVENTIONS

Relatively simple Relatively inexpensive Non-invasive All may be performed in GP offices, without

use of specialists Most care may be delivered by non-dentists

Hygienists Dental assistants

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DENTAL TREATMENT MODALITIES exams periodontal diagnosis prophylaxis scaling & root planing removal of hopeless teeth application of local antibiotic chips

such as Arestin

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PROGRAM BARRIERS FOR DENTISTS Reimbursement

Fear of treating sick patients

Perception of additional administration

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SOLUTIONS TO BARRIERS

provider education

additional compensation P4P Risk-adjusted rates Bonus for extending access

ease of administration including retrospective review of periodontal

treatment rendered

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COMPREHENSIVE CARE REQUIRES LINKING DENTISTS TO PHYSICIANS Connectivity with IT solutions to efficiently link

dentists with physicians and the plan Communications with PCPs – train them on

the dental care paths Patients – encourage them to speak with

their doctors Plan case managers – to refer patient back to

their doctors and provide additional home education

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CARE COORDINATION

Dental treatment as an addition to other health care modalities: medication dietary modification exercise smoking cessation physician follow up blood pressure lipid control weight management

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DENTISTS TAKING A LARGER ROLE IN THE SYSTEM blood pressure nutritional counseling smoking cessation Hg H1C BMI

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SELECTED PROVIDERS

Sub Network to provide these services: FQHCs (community health clinics)

Medical care Dental care Pharmacy Mental health care

other practices to be identified as Centers of Excellence

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THE ROLE OF NETWORK MANAGEMENT

Establish positive relationships Identification and outreach to appropriate

providers DM/Plan managers must be positioned as

provider advocates with focus on mutual patient care

Frequent contact to maintain constructive relationships and focus on the program

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NEW DENTAL PARADIGM

As pharma and behavioral health have been integrated intro primary care, so should dental care.

PHYSICAL DENTAL

PHARMA MENTAL

PRIMARY HEALTH

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ADMINISTRATION

Goal: Dental DM program to help control the high cost drivers of chronic care

Method: Program should mix short-term DM savings with long-term health status savings

Financial Translation: create a management program that helps reduce the medical trend

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INTEGRATED PROGRAM

Integrate the dental program with existing DM program:

1. Identify risk segment of population by severity2. Identify those conditions that would benefit from dental interventions3. Determine evidence-based care path to reduce risk4. Select and train providers for collaboration 5. Provide incentive to providers to engage in the program6. Encourage members to seek dental care7. Apply interventions (including claim edits for managing provider

utilization information)8. Train Case Managers to support dental care 9. Conduct data analysis to track the affect on program utilization,

costs and trends in program outcomes10. Report performance feedback back to network providers

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DENTISTS WILL BE SKEPTICAL!

Methods must not present onerous requirements, but small, steps to build successful partnering relationships retrospective pre-authorizations so as not to

inhibit chances of patient returning for their (perio) care

claim submissions using current processes risk-adjusted bonus payments that are paid

regularly

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CLAIM FORMUse of the REMARKS field on the claim

form.

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ADD CAPABILITY TO CLAIMS SYSTEM

Track the incidence (and severity) of care to those in the various targeted risk states: Diabetics CAD Pregnant women

Information may be amalgamated from the claims data to report risk corridors for the plan to address with education

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PLAN MUST ENSURE PROVIDER COMMUNICATION Physicians and nurse case managers rarely

get any education about dental care, yet they must refer patients on to dentists

Case managers or dental providers may report patient condition and care to PCPs (including OB/GYNs) Severe gum (periodontal) conditions Treatment plans

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FINANCIAL INCENTIVES TO DENTISTS Reward dental providers with risk-adjusted

payments Additional patient education provided Recall rates of targeted patients Pro-active assessment of payment status

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ProFile SYSTEM

Hand-held provider information database for network consultants to use when monitoring the network Detailed office information for case referrals In-depth knowledge of office capabilities Update on performance toward bonus payment

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QualDent ProFile System

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Assessment

Goal: Determine if the program is truly improving health status as it increases dental utilization

Method: Trend analysis according to the risk states to see if the expected loss ratio is affected

TO DO: calculate the trended regression of the mean for that segment of chronic membership (diabetics, pregnancies, cardiac patients)

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ROI Calculation

EXAMPLE: Diabetics cost companies around 35% more than non-diabetics. Is the cost (over time) with the Dental DM consistently less than the 35% we assessed in our population?

If the integrated program with dental will save more than the standalone medical DM program … then the program is a success! Typical savings around 4% to 5% for successful medical

DM

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SUMMARY

The opportunity for Dental DM in managed care programs is to increase short-term dental loss ratio, but decrease the more expensive, long-term medical loss ratio. Assess risk states affected by dental care Select and train providers Reward providers View data integrated with medical risk analysis

… all to develop a healthier member base